Health Care Homes: not yet where the heart is

Doctors have called on the Federal Government to delay the implementation of the Health Care Homes model from the current starting date of 1 July 2017 by at least three to six months. Here’s why.

United General Practice Australia, which comprises the leading general practice organisations RACGP, AMA, RDAA, GPSA, GPRA, ACRRM and AGPN, has serious concerns regarding capitated funding for chronic disease management and treatment. It may harm patients, and it may undermine GP-led care when funding runs out.

Additional time to plan for the Health Care Home model is required to get the nation’s healthcare system right and properly consider, design, and implement the supporting tools, information and adequate funding mechanisms.

The extended timeline would allow stakeholders time to ensure the instruments and tools being used are appropriate and validated by evidence.

Health Care Homes: the background

A Health Care Home (HCH) is not a place but a partnership between a patient, their GP and the primary care team. Health Care Homes are general practices and Aboriginal Community Controlled Health Services that coordinate the ongoing comprehensive care of patients with chronic and complex conditions.

As part of the 2016-17 Federal Budget, the Government announced the Healthier Medicare: Reform of the Primary Health Care System package. The core element of the package was the staged rollout of Health Care Homes in selected Primary Health Network regions starting in July 2017.

The Government has re-directed $21.3 million from the Practice Incentive Program and is redirecting a further $93 million in MBS funding to support the HCH trial.

HCHs have the potential to drive a fundamental shift in Australia’s health services toward patient-focused health care practices and are a modified version of the Patient-Centred Medical Home (the Medical Home).

The HCH aims to facilitate a partnership between individual patients, their preferred GP, and the extended healthcare team. The model should enable better-targeted and effective coordination of clinical resources to meet patients’ needs.

Patient-centred Medical Homes have been associated with increased access to appropriate care and decreased use of inappropriate services – particularly emergency departments – for patients with chronic and complex conditions.

The clinical team– which may include GPs, nurses, nurse practitioners, Aboriginal health workers, care coordinators, allied health professionals and other medical specialists – collectively provides care for patients.

The HCH aims to meet as many of the patient’s healthcare needs as possible and for collaborating with other health and community services.

In the current proposal Health Care Homes will receive monthly ‘bundled payments’ on a per patient basis, depending on each eligible patient’s level of complexity and need. The payments will be paid to the Health Care Homes, not GPs.

All general practice healthcare associated with the patient’s chronic conditions, previously funded through the MBS, will be funded through the bundled payment. Regular fee-for-service will remain for routine non-chronic disease-related care patients.

Funding for services provided by allied health professionals and specialists, as well as for diagnostic and imaging services are not included in HCH bundled payments and will continue to be funded through the MBS.

Stage one is limited to Medicare-eligible patients with two or more complex or chronic conditions. Patients that fall within three identified tiers will be eligible to enrol in a Health Care Home.

The Department of Health is developing a patient identification tool to be used by HCHs to identify eligible patients as per the tiers. The Department states that the tool will attribute a risk score to each patient, which will determine the level of care required and subsequently the value of quarterly bundled payments that HCH will receive.

Unfortunately details on the eligibility assessment tool have not yet been released, but will likely draw upon information the practice already has on the patient (for example previous hospital admissions, diagnosis, medications, clinical risks), as well as non-clinical information such as demographic and psychosocial factors.

The patient identification process will be the same across all stage-one HCHs, regardless of whether or not they are in rural and remote areas.

The Practice Incentives program (PIP), a key driver of quality care in general practice, is currently undergoing reform. The redesigned PIP program will reportedly introduce a quality improvement incentive to replace the clinical specific incentives in the current PIP and provide a ‘flexible and supportive structure to the HCH implementation’.

Stage one of the implementation is currently set to commence on 1 July 2017 and run for two years until 30 June 2019. It will involve approximately 65,000 patients and up to 200 general practices or Aboriginal Community Controlled Health Services.

Medical Home RACGP
Key elements of the medical home. Source: RACGP

Why doctors have expressed concerns

One of the key recommendations by the Primary Health Care Advisory group was to encourage patients to be engaged in their care (recommendation 3). Although the model was intended to be ‘patient-centred’, the patient somehow seems to have been lost in the discussion around the current model.

For example, it is not clear how the proposed model will encourage better coordination or comprehensiveness of care to improve the patient journey (recommendation 7).

For a long time the RACGP and other professional groups have been actively offering to work with the Government on the development of an appropriate model, but the RACGP and other GP groups were not consulted in this case. The general practice representatives on the Government’s implementation committees are not representing their professional associations and furthermore have had to sign confidentiality agreements so therefore cannot discuss ideas and recommendations with peers or policy development staff.

The Government claims that it is implementing a model based on the RACGP vision. Unfortunately the current Health Care Homes proposal by the Department of Health does not reflect the RACGP’s evidence-based, best practice model of the Medical Home, as outlined in the RACGP Vision for general practice and a sustainable healthcare system.

The RACGP has called for a rigorous trial subject to academic and scientific evaluation, rather than rushing into a phased rollout. The HCH implementation evaluation methodology is still under development. Health policy needs to be evidence-based and the evidence should to be carefully developed – otherwise it will fail patients and the Australian health system.

A correctly designed trial will properly address the challenges facing Australia, strengthen access to the delivery of high-quality care and ensure patients have a stable and ongoing relationship with a general practice.

The proposed model capitates funding for chronic disease management and treatment in general practice. It may harm patients and undermines GP-led care when funding runs out.

This major reform, which is expected to save millions of dollars in hospital care, did not receive additional funding. GP groups are concerned that the federal Government’s Health Care Homes model is inadequately funded and will not improve health outcomes for millions of Australians living with chronic and complex conditions.

An example of concerns

HCHs will be required to have a service or care coordinator for enrolled patients. As funding allocated to the HCH is in fact reallocated funding from PIP and Medicare, there is no additional money available to support this role.

There is presently not enough information available for practices to make an informed business decision about their involvement with the HCH.

Information released by the Government does not provide details on any additional support for e.g. practices in rural and remote areas and no additional funding is being provided for these areas, where there are higher costs and complexity in providing chronic health care.

The original RACGP Medical Home vision includes incentives for practices and GPs to facilitate patient-centered care, for example a complexity loading to support the delivery of patient services in areas of community need.

The RACGP vision also recommends a comprehensiveness loading: GPs and general practices that provide a comprehensive range of services can respond to the needs of the community they serve. Enhancing the comprehensiveness of services provided in the primary health sector will reduce demand for more complex and expensive services in the secondary and tertiary health sectors.

Medical Home model (RACGP)
Table: Activities and infrastructure required to achieve healthcare sustainability according to RACGP. There is a clear distinction between the Government’s HCH funding model and the RACGP Medical Home model. Source: RACGP.

The Department has indicated that payments made to a HCH are also intended to cover after-hours services where they are provided in the practice rooms. Some practices may achieve efficiencies by providing some care for enrolled patients over the phone or electronically.

Each practice will need to determine if the allocated funding in the proposed model is sufficient to provide the additional care required under the HCH model.

The Department has stated that successful HCH applicants will receive a one-off payment of $10,000. The RACGP believes that an appropriately funded HCH trial would require an average of $100,000 per practice per annum, in addition to current funding allocations for chronic disease management items and other MBS items.

As the funding of the HCH by the Federal Government is minimal, additional funding from State Governments and Private Health Funds may be necessary to make the model a success. The federal Government could assist by negotiating such payment levels as part of the HCH.

The RACGP is prepared and ready to work closely with the Federal Government on this major health reform – let’s not miss the opportunity to make Health Care Homes a success.

This article was originally posted on Croaky. Dr Edwin Kruys is vice-president of the Royal Australian College of General Practitioners (RACGP). 

The information in this article is based on public material provided by the Department of Health. Whilst all efforts have been made to ensure the details are accurate, information regarding Health Care Homes is subject to change.
Follow me on Twitter: @EdwinKruysDisclaimer and disclosure notice.

Table: Health Care Home requirements

(Source: Department of Health)

A general practice or Aboriginal Community Controlled Health Service applying to be a Health Care Home must be within one of the ten selected PHN regions and needs to:

  • be accredited and maintain accreditation, or be registered for accreditation, against the RACGP Standards for general practices;
  • participate in, or be prepared to participate in, the Practice Incentives Program (PIP) eHealth Incentive;
  • register and connect to the My Health Record system and contribute to their enrolled patients’ My Health Records;
  • participate in the stage one HCH training program;
  • use the patient identification tool to identify the eligible patient cohort in their practice or service, assess individual patient eligibility and stratify their care needs to one of three complexity tiers according to their level of risk;
  • ensure that all enrolled patients have a My Health Record;
  • contribute up to date clinically relevant information to their patients’ My Health Records;
  • develop, implement and regularly review each enrolled patient’s shared care plan;
  • provide care coordination for enrolled patients;
  • provide care for enrolled patients using a team-based approach;
  • ensure that all team members have roles that utilise their qualifications and allow them to work to their scope of practice;
  • provide enhanced access for enrolled patients through in-hours telephone support, email or video-conferencing, as well as access to after-hours care where clinically appropriate;
  • ensure that all enrolled patients are aware of what to do if they require access to after-hours care;
  • collect data for the evaluation of stage one and for internal quality improvement processes.

Health Care Home for sale?

The government seems to have lost the goodwill of the profession about their Health Care Homes model. On Friday afternoon the details of implementation stage 1 were published and it was underwhelming – to say the least.

A health reform like this, which should focus on better integration, coordination and team care, must be planned and rolled out in collaboration with the profession and consumers, not quietly published on a Friday afternoon.

Despite initial reassurances from Federal Health Minister Sussan Ley, there has been no consultation. Many GPs have expressed concerns during the weekend or indicated that they have lost interest in the model.

Restricted Medicare access

The government’s Health Care Homes model does not reflect the RACGP’s best practice model of the medical home, as outlined in the RACGP Vision for general practice and a sustainable healthcare system, released in September 2015.

Several details of the government’s proposed model, including the risk stratification tool, are not yet available. What happened to support for multidisciplinary team care, comprehensiveness loading (incl for rural and remote areas) and realigning PIP and SIP funding?

Under the model support payments for chronic disease management will be bundled, with enrolled patients eligible for only 5 non-chronic disease related services per year. Restricting access to acute care for people with chronic and complex conditions is not helpful and puts patients at risk.

Underfunded trial 

RACGP president Bastian Seidel said: “At best, it is a two year underfunded trial on the effects of inadequate capitation funding. It will put financially vulnerable patients at risk of not having access to Medicare rebates when they seek care that is not associated with their predetermined chronic health condition.”

It is difficult to comprehend that the government acknowledges there is a growing problem with regards to Australians living with chronic & complex conditions, it wants major reform to tackle this issue but is not prepared to invest in a sustainable, evidence-based and cost-saving model supported by the profession and consumers – and does not consult.

The proposed model is inadequately funded and will likely fail to improve health outcomes for Australians living with chronic and complex health conditions. I’m sure the government can do better than this.